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<br />to <br /> Grade B Dairy Milk Dispenser-Number of Containers in Multi-Head Unit <br /> Program 3 Facility <br /> Natural Bathing Area Spa Out of Service Pool/Spa Pool <br /> Kennel <br /> Ag/Cannery Waste Site <br /> Process/Recycle Facility <br /> Dumpsters > 20 cu yd (# of Units) <br />to <br />(O KT <br /> License # <br /> Package Treatment Plant <br />Square Footage Food Handlers Course required: Yes No <br /> with Food Preparation DVending Machines Number of Units <br /> w/Meat Market only Multiple Departments Prepackaged Goods Only <br /> Vehicle Type Color <br /> License# Sticker# <br /> Vehicle Type Color <br /> License# Sticker# <br /> Ice Plant Produce Stand <br /> CFO A B <br />s <br /> Capacity <br /> Chemical Toilets —Number of UniBE/^r-n j—— <br /> FSWH«<MfflbiRie?jiwi’rVite <br />environmental <br />□ Small Generato^J Lmnre^fi^^T <br /> 11 - 60 > 60 generators <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />/ MASTERFILE RECORD INFORMATION FORM <br />Im New EH Program at Existing Facility________________ PNew EH Program and New Facility <br />Facility ID Program Record ID || <br />Facility Address CZ- <br />(Please check the appropriate description and specify size, number of units and pertinent information ) <br />FOOD PROGRAM (1600) <br /> Restaurant: Seating Capacity <br /> Commissary Dry storage only <br /> Retail Market—Square footage <br /> Mobile Food Vehicle --Make <br />Registration # <br /> Mobile Food Prep Unit-- Make <br />Registration # <br /> Temporary Food Facility -Dates of operation from <br />"'JSi^special Event—Dates of operation from lb (I <br />DAIRY PROGRAM (2000) <br /> Grade A Dairy <br />CUPA <br /> Hazardous Materials Business Plan (1900) Number of chemicals: <br /> CalARP Program Program 1 Facility Program 2 Facility <br /> Hazardous Waste Generator (2200)----------->-Tons Generated Per Year <br /> Tiered Permitting Facility--------> CA (2232) CE (2233, 2234, 2235, 2237) PBR (2231) PBR HHW (2236) <br /> Aboveground Storage Tank Facility (AST) (2800) Number of ASTs <br /> Underground Storage Tank Program (UST) (2300) Use UST A and B forms <br /> Other CUPA Program <br />HOUSING PROGRAM (2400)□ Hotel/Motel------Number of Units □ Jail or Exempt Institution -—Number of Units <br />Employee Housing (2700) Use Employee Housinq/Labor Camp Application Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL (3000) <br /> Environmental Assessment UST-CAP Site Local HW Cleanup Site NPL/SEP Cleanup Site UIC Site <br /> Abandoned HW Site non-NPL/SEP Cleanup Site RWQCB Cleanup Site Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility <br />VECTOR CONTROL PROGRAM (4000) <br /> Poultry Farm-Maximum number of birds <br />TATTOO, BODY PIERCING, PERMANENT COSMETIC PROGRAM (4100) <br /> Body Art Practitioner Reg (4110) Mechanical DSPS Notification (4115) Body Art Facility-Single Use (4120) <br /> Body Art Facility-Sterilization (4121) Body Art Temp Event Co-ord (4130) Body Art-Temp Event Mobile Facility (4131) <br />LIQUID WASTE PROGRAM (4200) <br /> Pumper VehicleRegistration # <br /> Pumper Yard <br />SOLID WASTE PROGRAM (4400) <br /> Landfill Transfer Station <br /> Waste Tire Facility Compost Facility <br /> Refuse Vehicles (# of units) <br />MEDICAL WASTE PROGRAM (4500) <br /> Primary Care Acute Care Skilled Nursing Large Generator <br /> Transfer Station Veterinary Clinic Common Storage Facility □2-10 <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS EHD 46-02-003 Blue Application Form <br />i] T. , Emergency Notification for this FACILITY and/or PROGRAM . <br />CONTACT PERSON VC lC'lA} G'- \ n —Day Ph /flight Ph x / <br />Program Element I 5 Fee ■ 1 ____________ Surcharge Fee /_______ Other Fee_______________ <br />Inspector# 'aA rTv, Permit Valid Z- / / to_____________________ □ Food Handler__________ <br /> Check # L> Amount Paid_________7 A-— Date . Invoice # <br />$ Cash Reviewed by ;■_______________Accounting Office J______ ____________Date <br />48-02-034 1 " MASTERFILE RECORD INFORMATION PINK <br />1/23/13 \